DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant...
Transcript of DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant...
![Page 1: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/1.jpg)
Welcome to the webinar:
DLD - When is a diagnosis appropriate?
Wednesday 4th November 20201pm
![Page 2: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/2.jpg)
Developmental Language Disorder Day • October 16th 2020
• Ireland to Saudi Arabia, Hong Kong to Brazil
• Over 80 light up events. Blackpool Tower, Birmingham Library and Portsmouth Spinnaker.
• COVID-19 did not stop our 700+ RADLD ambassadors
• 500,000 tweet impressions. One Facebook post seen by over 50,000
• #DLDseeMe trending number 2, German equivalent at 7.
• YouTube: multilingual video and a video made entirely by adults with DLD
• Run by 6 volunteer international committee members
• Keep an eye on Facebook and Twitter for 2021 date
![Page 3: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/3.jpg)
Diagnosing DLD or Language
Disorder (associated with X)
Dr Susan Ebbels@SusanEbbels @MHResTrain
Moor House Research and Training Institute;
Department of Language and Cognition, UCL.
With many thanks to Dorothy Bishop
![Page 4: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/4.jpg)
Why diagnose Language Disorder / DLD?
● consistent use of terminology facilitates communication between professionals
● parents can
○ find out info re their child’s difficulties
○ connect with other parents
○ access and advocate for appropriate support and services
● This is a core function of paediatric SLTs
![Page 5: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/5.jpg)
Lack of awareness leads to limited:
• referrals and diagnosis• information • support• services• research
vicious circle
From McGregor (2020) How we fail children with DLD. Language Speech and Hearing Services in Schools
![Page 6: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/6.jpg)
Associated withbiomedical condition, X*
Language disorder
Child with language difficulties that:• significantly impair social and/or
educational functioning• with indicators of poor prognosis
Developmental language disorder
(DLD)
Language disorder associated with X*
*includes genetic syndromes, a sensorineural hearing loss, neurological disease, ASD or Intellectual Disability
Important!Not exclusionary
factors.Child eligible for
assessment/ intervention
Starting point
Unlikely to resolve by five years of age – does NOT mean cannot be diagnosed before 5 years
In most cases, SLTs should be able diagnose Language Disorder without needing MD Team
Also means can be diagnosed in adults
![Page 7: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/7.jpg)
At what age can I diagnose Language Disorder/DLD?
If still have significant problems with language at 5 years, very unlikely to resolve spontaneously, so meet criteria for poor prognosis
Diagnosis can also be made in younger children if they have indicators of poor prognosis –• poor language comprehension,
• several areas of language affected
• poor use of gesture,
• family history of language impairment, and/or
• poor response to intervention
More risk factors = more chance of persisting difficulties
![Page 8: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/8.jpg)
So what term should I use for a 3 year old with language difficulties?
• DLD / Language Disorder if have many indicators of poor prognosis
• If few indicators of poor prognosis, do NOT use “disorder”, but use
– “language difficulties”, or
– “SLCN”, but
– NOT “language delay”
8
![Page 9: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/9.jpg)
Language Disorder is a subset of broader category of SLCN
Language DisorderSpeech, Language andCommunicationNeeds
![Page 10: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/10.jpg)
Associated withbiomedical condition, X*
Language disorder
Child with language difficulties that:• significantly impair social and/or
educational functioning• with indicators of poor prognosis
Developmental language disorder
(DLD)
Language disorder associated with X*
Important!Not exclusionary
factors.Child eligible for
assessment/ intervention
*‘Associated with’ does NOT mean ‘explained by’, or ‘caused by’- ‘and’ might have been clearer!
![Page 11: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/11.jpg)
Associated withbiomedical condition, X*
Language disorder
Child with language difficulties that:• impair social and/or educational
functioning• with indicators of poor prognosis
Developmental language disorder
(DLD)
Language disorder associated with X*
9.92%
7.58%2.34%
![Page 12: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/12.jpg)
DLD is a subset of Language Disorder
12
Language Disorder
Developmental Language Disorder
Language Disorder
Speech, Language andCommunicationNeeds
![Page 13: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/13.jpg)
This definition of DLD very broad: need additional informationNature of language impairments• Phonology• Syntax• Semantics• Word finding• Pragmatics/language use• Verbal learning & memory
Decided against subtypes – too many children don’t fit neatly!
Risk factors• Family history • Poverty• Low level of parental education• Neglect or abuse• Prenatal/perinatal problems• Male
Co-occurring disorders• Attention• Motor skills• Literacy• Speech• Executive function• Adaptive behaviour• Behaviour
• May have multiple diagnoses• These may also need intervention• Can be difficult to disentangle the
effects of co-occurring disorders, especially with increasing age
![Page 14: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/14.jpg)
14
![Page 15: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/15.jpg)
Associated withbiomedical condition, X*
Language disorder
Child with language difficulties that:• impair social and/or educational
functioning• with indicators of poor prognosis
Developmental language disorder
(DLD)
Language disorder associated with X*
*‘Associated with’ does NOT mean ‘explained by’
![Page 16: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/16.jpg)
What is included in ‘biomedical condition?
Language disorder associated with
• Known genetic condition (e.g. Down syndrome, Klinefelter syndrome)
• Acquired brain injury
• Sensorineural hearing loss
• *Intellectual disability
• *Autism spectrum disorder
*Included because of growing evidence of genetic basis for these conditions
Remember:Not exclusionary
factors.Child eligible for
assessment/ intervention
![Page 17: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/17.jpg)
What is included in ‘biomedical disorder’?
Language disorder associated with
• Known genetic condition (e.g. Down syndrome, Klinefelter syndrome)
• Acquired brain injury
• Sensorineural hearing loss
• *Intellectual disability
• *Autism spectrum disorder
*Included because of growing evidence of genetic basis for these conditions
Remember:Not exclusionary
factors.Child eligible for
assessment/ intervention
![Page 18: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/18.jpg)
Why are these differentiated from DLD?
• Additional problems associated with the biomedical condition likely to have an important influence on nature and prognosis of language problems
• Assumption (though little evidence!) that the associated condition may require a different intervention pathway
• For research on aetiology, inclusion of cases with known biomedical conditions would muddy the picture
• In some cases, the biomedical condition may be unrelated to the language disorder, but still needs to be noted, e.g., could use “DLD and epilepsy”
![Page 19: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/19.jpg)
What term should I use if I’m not sure if there are differentiating conditions?
• Diagnosis of differentiating conditions likely to need MD team
• If you suspect a differentiating condition, use umbrella term “Language Disorder” until more information available
![Page 20: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/20.jpg)
Hearing impairment
20
![Page 21: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/21.jpg)
Sensorineural hearing loss
Maybe use “DLD and SNHL/deafness” for
• Deaf child who has difficulty learning sign language.
• aurally-educated child with disproportionate language learning problems relative to level of deafness.
because the serious nature of language problems might get overlooked if just diagnosed as ‘Language disorder associated with SNHL’
This area needs further discussion
Whatever terminology we use, these cases should not be excluded from SLT as they have needs
![Page 22: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/22.jpg)
Intellectual disability
22
![Page 23: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/23.jpg)
How is Intellectual Disability defined?
Traditionally defined in terms of non-verbal IQ below 70. Now modified:
“The diagnosis in DSM-5 will emphasize both clinical judgment and standardized intelligence testing”
• Less emphasis on IQ score (hence why EPs may not be doing)
• Greater emphasis on adaptive reasoning in academic, social, and practical settings
• Lack of personal independence a criterion
Harris, J. C. (2013). New terminology for mental retardation in DSM-5 and ICD-11. Current Opinion in Psychiatry, 26(3), 260-262.
![Page 24: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/24.jpg)
Reilly et al. (2014) IJLCD
• cut-off points
are
completely
arbitrary!
No children with low language
and high non-verbal IQ
Lots of
children
with low IQ
and OK
language
• ? low
language
restricts non-
verbal
performance,
not vice
versa!
![Page 25: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/25.jpg)
DLD does not exclude children with low-average IQ
Population survey of children in Surrey (Norbury et al., 2016):• DLD with low-average IQ (70-85) do not differ from
traditional SLI (>85) on:– Language & communication,
– social, emotional, behavioural probs,
– academic attainment
– they only differ on NV IQ
But those with Language Disorder associated with X differ from the others on all of the above
![Page 26: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/26.jpg)
If I suspect intellectual disability, but waiting for views of MD team, what
label do I use?
• If unsure -> “Language Disorder” until diagnosis given or rejected
• Remember low language may be influencing cognitive performance rather than vice versa, so DLD may be appropriate if don’t meet criteria for intellectual disability, but have poor functioning in class
![Page 27: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/27.jpg)
ASD
![Page 28: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/28.jpg)
Why is ASD included as ‘biomedical condition’? What about ‘Social
Communication Disorder’?
Two thorny issues:
1. Not clear which professional group have ‘responsibility’ for SCD (a diagnosis used when there are ASD features but without repetitive behaviours), whereas ‘pragmatic language disorder’ is seen as falling in the domain of SALT
1. What about children with ASD who also have structural language problems characteristic of DLD?
![Page 29: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/29.jpg)
Language problems in autism: how do they relate to DLD?
Autisticdisorder
DLD
Many have structural languageproblems resembling DLD
Some have pragmatic problems similar to those in ASD
![Page 30: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/30.jpg)
Social Communication Disorder (SCD)
Autisticdisorder
DLD
SCD
![Page 31: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/31.jpg)
In practice boundaries hard to draw
Autisticdisorder SCD DLD
CATALISE does not recommend SCD: “we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder.”Children with ASD should have language assessment, and where they have ‘Language Disorder associated with ASD’ then SLT should be considered
![Page 32: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/32.jpg)
If I suspect ASD, what label do I use?
• If unsure -> “Language Disorder” until diagnosis given or rejected
• If ASD diagnosis ruled out: “DLD”.
– describe language impairment & co-occurring disorders, e.g., Co-occurring disorders
• Attention• Motor skills• Literacy• Executive function• Behaviour
Nature of language impairments• Semantics• Pragmatics/language use• Verbal learning & memory
• if ASD diagnosis: “Language Disorder associated with ASD”– describe the language impairments (e.g., syntax) too
![Page 33: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/33.jpg)
Intervention and educational provision
• Diagnosis may be the first step to unlock intervention and educational support, but…
• Intervention and educational provision should be based NOT on the diagnosis, but on the child’s detailed profile, severity and functioning in their current environment
• Therefore need for intervention and nature of that intervention may change with time even if the core difficulties remain
![Page 34: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/34.jpg)
Thank you for listening
Please type questions in the Q&A
![Page 35: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/35.jpg)
Welcome
Gill Earl
![Page 36: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/36.jpg)
Case study 1
Background Information
Child: R Gender: male language(s): English
Request for Assistance from nursery – first seen by SLT age 4:0
• no reported ACES - supportive family
• no significant medical or family history
• late talker, other developmental milestones WNL
• limited language reported
• speech – unclear
SLT assessment
• multiple developmental phonological processes (CLEAR)
• spontaneous communication- few words, set phrases, gesture, pointing
• 2nd centile for receptive vocabulary (BPVS)
• very limited ability to express ideas – telegrammatic (RAPT)
![Page 37: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/37.jpg)
Other assessment
• community paediatrician – ASD considered – diagnosis not given
Diagnostic considerations
• differential diagnosis – DLD vs. late talker vs. ASD +/- learning
difficulties, +/- SSD
SLT intervention
• phonological awareness
• speech (phonological) therapy
• early language (listening, following instructions, functional
vocabulary, language for specific activities/contexts)
🡺 improvement in speech – most pL processes resolved by age 6
🡺 struggled with syllables and rhyme
🡺 slow process with language
![Page 38: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/38.jpg)
Diagnostic considerations II
• not SSD – but ? risk for dyslexia
• few signs of ASD and excluded by CCH
• probable DLD – discussed with family and teacher / support for learning
Further assessment (age 5)
• CELF IV – all standardised scores = 1, composite language score = 40
• RAPT – extremely low grammar score (8), information (22). Expressive
language contains no conjunctions, few SVO clauses or tense marking
• word retrieval becoming more apparent as vocabulary increases
Conclusion
Diagnosis of DLD given by SLT age 5 on basis of:
• severe difficulties with both receptive and expressive language
• persistent difficulties
• no identifiable biomedical conditions
• impact on social interaction, academic progress and wellbeing.
![Page 39: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/39.jpg)
Impact of DLD diagnosis
Parents:
● Helpful to receive a diagnosis – provides some answers
● Appreciate information provided by SLT service
● Frustration that DLD is not yet widely understood
● Internet searches – not always helpful 🡪 anxiety /
frustration
● Challenged by slow progress and life-long nature of DLD
Further information: (now aged 8:6)
• significant literacy difficulties despite intensive support
• full-time PSA –learning and behaviour (aggression/frustration)
![Page 40: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/40.jpg)
Any Questions?
![Page 41: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/41.jpg)
Developmental Language Disorder
Diagnosis survey
What are the issues for Speech and Language Therapists
across the UK?
What guidance and training will make a difference for you?
Survey is for ALL Speech and Language Therapists NOT just
specialists
Google form
10 minutes
Please complete and share widely:
https://forms.gle/xsXyKjLwezZWQrMj7
![Page 42: DLD - When is a diagnosis appropriate? · •no reported ACES - supportive family •no significant medical or family history •late talker, other developmental milestones WNL •limited](https://reader035.fdocuments.net/reader035/viewer/2022071414/610d8a6cc79f6734e573f5ce/html5/thumbnails/42.jpg)
Join us for the next webinar
www.rcslt.org/webinars